Many of the nontransplant physicians who manage hepatic patients (internists and hepatologists) keep asking about liver transplantation. The purpose of this article is to highlight important topics a nontransplant colleague may require in his practice. There are many topics in this respect; however, three most important topics need to be highlighted; those are; the time of referral to transplantation, the indications and contraindications and the metabolic issues regarding a transplanted patient. Still, there are no clear guidelines for the management of many of the metabolic issues regarding liver transplanted patients. And this why, collaborative efforts of transplant and nontransplant physicians are needed to conduct multicenter, long term randomized controlled trials and proper follow up programs.

Introduction
Melatonin is a pineal hormone under the control of the biological clock, which is located in the hypothalamus and regulated by light exposure. Melatonin receptors have been found throughout the body in many tissues including pancreatic islet cells, reflecting the widespread effects of melatonin on physiological functions such as energy metabolism and the regulation of body weight. Several lines of evidence suggest that melatonin may play a role in glucose metabolism.
Aim of the work
To investigate the association between diabetes mellitus (T2D) and the variants rs10830963 in the melatonin receptor 1B gene (MTNR1B) locus in a sample of the Egyptian population.
Patients and method
This was a case-control study conducted in the internal medicine department at El-Kasr El-Aini Hospital, Cairo University.
It included 30 diabetic individuals (type 2) compared with 20 healthy individuals. All individuals included in the study were subjected to a detailed history taking, complete physical examination, body composition evaluation, and laboratory testing including blood picture, blood urea nitrogen, creatinine, lipid profile, and genotyping of melatonin receptor B1. Diabetic individuals were subtyped into three groups: (a) Diabetic patients without complications. (b) Diabetic patients with microvascular complications. (c) Diabetic patients with macrovascular complications.
Results
Statistical analysis revealed a significant positive correlation between the MTNR1B polymorphism rs10830963 and glucose levels in type 2 diabetes.
Conclusion
The study confirmed that individuals having the MTNR1B gene polymorphism are at a greater risk of developing type 2 diabetes and having higher blood glucose levels and are more prone to be dyslipidemic than others who have no polymorphism.

Evaluation of false remission in ulcerative colitis and the need for a revised disease activity index

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Alaa Elgamal, Hanan MakloufDOI:10.4103/1110-7782.148129

Aim of the work
To highlight some criteria of remission in ulcerative colitis, to address the issue of false remission, and settle a standard index for its detection.
Patients and methods
Patients with ulcerative colitis in clinical remission were enrolled prospectively and followed for 1 year for evaluation of clinical manifestations, C-reactive protein, fecal calprotectin, and tumor necrosis factor-α, and colonoscopic and microscopic examination for the detection of actual remission, with the exclusion of those who developed clinical relapse during the study.
Results
Out of 36 patients, we had 11 patients (30.5%) with true remission and 25 patients (69.5%) with false remission: 19 patients (52.7%) in false remission group A with abnormal mucosal healing and six patients (16%) in false remission group B with high inflammatory markers.
There was a significant positive correlation of inflammatory markers with the ulcerative colitis disease activity index in patients with true remission. There was a significant correlation of the ulcerative colitis disease activity index and histological grades in false remission A and a significant correlation of inflammatory markers with histological grades in false remission B.
Conclusion
About 70% of our patients with ulcerative colitis in clinical remission had an active disease. Clinical remission in ulcerative colitis can be best expressed as true and false remission depending on histological grading in a revised ulcerative colitis disease activity index. Some inflammatory markers can be useful for the detection of true remission.

Background
The pathophysiology of type II DM is complex; in addition to impaired insulin secretion from Beta-cells, reduced insulin sensitivity was found to play a predominant role in the pathogenesis of the disease. Fetuin-A is a he­patic secretory protein that binds the insulin receptor and inhibits insulin action both in vivo and in vitro.
Objective
Our aim was to investigate whether serum fetuin-A levels predict the incidence of insulin resistance in type II DM.
Patient and methods
The present study included 40 patients who had type II diabetes mellitus served as patients group and 40 apparently normal individuals served as control group. All patient and control groups were subjected to the following: full medical history and thorough physical examination, fasting & post prandial blood glucose, urea, creatinine, lipid profile, CRP, insulin and fetuin-A.
Results
There was highly significant increase in serum insulin, serum fetuin A and HOMA-IR in diabetic group compared with control group. There was significant positive correlation between serum fetuin A and serum insulin, FBG, HbA1c and serum CRP. Also a significant positive correlation between HOMA-IR and serum fetuin A, serum insulin and HbA1c were found.
Conclusion
We concluded that fetuin-A may play a role in the pathogenesis of type II DM, and high serum fetuin-A has a strong association with IR and glycemic control in type II diabetic patients. Future studies are recommended to establish the possibility of using fetuin-A as a predictor of insulin resistance in type II diabetic patients.

Background and objectives
Nonalcoholic fatty liver disease (NAFLD) is a common chronic liver disease that includes a spectrum of liver diseases ranging from simple steatosis to steatohepatitis, fibrosis, and cirrhosis. Liver biopsy is the current gold standard for the assessment of fibrosis in patients with NAFLD. However, it is an invasive procedure and not free from complications. We aimed to analyze the diagnostic performance of simple noninvasive scoring systems for the detection of fibrosis in Egyptian patients with NAFLD.
Patients and methods
Seventy-six patients with biopsy-proven NAFLD were included in the study. Noninvasive scoring systems included AST/ALT ratio (AAR), APRI score, BARD score, FIB-4 score, and NAFLD fibrosis score (NFS). Patients were classified into two groups according to the grade of fibrosis in liver biopsy. Group 1 included 57 patients with no or mild fibrosis (stage 0-2) and group 2 included 19 patients with advanced fibrosis (stage 3-4). The sensitivity, specificity, positive predictive values, negative predictive values, and diagnostic accuracy for relevant cut-offs and area under receiver operating characteristic curves were determined.
Results
The area under receiver operating characteristic curves for advanced fibrosis were 0.936 for the FIB-4 score, 0.916 for NFS, 0.907 for the APRI score, 0.840 for AAR, and 0.556 for the BARD score. NFS and the FIB-4 score showed the best diagnostic accuracy (92.6 and 89.7%, respectively), followed by the APRI score (75%), AAR (40.8%), and the BARD score (39.5%).
Conclusion
FIB-4 and NFS can be used reliably to diagnose or exclude advanced fibrosis in NAFLD and thus reduce the burden of liver biopsies.

Background and aim
Ascites in liver cirrhosis is associated with a poor prognosis and impairment of the quality of life and may be complicated by hepatorenal syndrome. Renal functions and haemodynamic changes after large-volume paracentesis (LVP) in cirrhotic patients with tense ascites were evaluated.
Patients and methods
A total of 50 cirrhotic patients with tense ascites were divided into two groups: group I 25 patients without renal impairment and group II 25 patients with renal impairment (type II hepatorenal syndrome).
Results
In groups I and II, the serum creatinine decreased significantly 24 h after LVP (P < 0.05 and 0.01, respectively). The glomerular filtration rate and the urine output increased significantly 24 h after LVP (P < 0.05, P < 0.01 and P < 0.01, P < 0.05, respectively, in groups I and II). The renal artery resistive index (RI) was significantly higher in group II compared with group I (P < 0.01). LVP caused a significant increase in the cardiac output, the stroke volume and the cardiac index (P < 0.01) and a significant decrease in the RI in both groups (P < 0.01). There was significant correlation between serum and ascetic fluid electrolyte levels in all patients.
Conclusion
LVP causes a significant reduction of heart rate and mean arterial pressure, serum creatinine, blood urea nitrogen and RI with a significant glomerular filtration rate increase, but had no effect on the plasma renin activity.

Poisoning with chromium is fatal and rarely reported. We report a case of a 25-year-old man who developed severe acidosis, gastrointestinal hemorrhage, and acute kidney and hepatic injury following homicidal ingestion of chromium. Patient improved after multiple cycles of alternate day hemodialysis.

Diagnosis of Guillain-Barrι syndrome (GBS) is established clinically and is supported by nerve conduction studies and cerebrospinal fluid examination. Renal function is usually not affected, but recent case reports have established a link between GBS and hyponatremia. A 60-year-old woman presenting with lower back ache since 3 days, became drowsy the next day and developed paraparesis and bulbar symptoms. Her sensorium and power deteriorated progressively over the next 2 days and she was brought to hospital in a drowsy state. She was found to have severe hyponatremia (Na + at 113) and nerve conduction study (NCS) was son of AMAN. The patient was started on intravenous immunoglobulin and her sodium levels were corrected, and the patient recovered completely. The occurrence of hyponatremia in patients diagnosed with GBS is well described. However, there have been only two prior case reports in which hyponatremia had been observed before the manifestation of neuromuscular deficits. Our patient case is unique in that severe hyponatremia occurred simultaneously with neurologic symptoms and the diagnosis of GBS. In most cases reported in the literature, hyponatremia was noted after a diagnosis of GBS was established. The mean period of onset of syndrome of inappropriate antidiuretic hormone (SIADH) was 8.8 days after the onset of symptoms of GBS. In conclusion, this presentation raises the possibility that early changes in the autonomic nervous system triggered by GBS might lead to alterations in water and sodium balance that can precede symptomatic changes in the peripheral nervous system. Although rarely, but both GBS and its treatment, intravenous immunoglobulin, should be considered in the differential diagnosis of hyponatremia.

Oncocytic neoplasms are well recognized in organs such as the kidney, thyroid and salivary glands. They are seen rarely in other sites such as the adrenal cortex. To date, around 20 cases of oncocytic adrenocortical neoplasm have been reported; most of them were benign and nonfunctioning. We report the case of hypersecreting adrenocortical oncocytoma in a 52-year-old woman. The patient was tested because of cushingoid features. The patient underwent a laparotomy for right adrenal gland mass. The pathology report confirmed adrenocortical oncocytoma.